Risultati per: Follow-up ottimale dopo embolia polmonare acuta

Circulation, Volume 146, Issue Suppl_1, Page A15218-A15218, November 8, 2022. Background:Cardiac amyloidosis (CA) is most commonly caused by the infiltration of misfolded amyloid transthyretin (ATTR) or light chain (AL) molecules in the myocardium. The workup for CA requires serum assessment to exclude the rapidly progressive AL subtype before imaging to assess the more common and indolent ATTR form. The diagnostic algorithm has the potential to become complex as in this case about a woman with Sjogren’s syndrome which predisposes to plasma cell dyscrasias.Case:A 68-year-old female with congenital long QT syndrome requiring implantable cardioverter-defibrillator (ICD), bilateral carpal tunnel, and recent diagnosis of Sjogren’s syndrome was found to have new systolic heart failure during workup for interstitial lung disease. Labs revealed pancytopenia, abnormal kappa/lambda ratio (2.25), and polyclonal gammopathy on immunofixation. Echocardiogram showed moderately reduced systolic function with an ejection fraction of 35-40% and moderate concentric left ventricular hypertrophy.Decision-making:Cardiology obtained cardiac magnetic resonance imaging (CMR) that returned indeterminate due to ICD artifact. Hematology performed a bone marrow biopsy that was negative for plasma cell dyscrasia, though stained positive for amyloid on congo red with mass spectrometry revealing the valine 142 isoleucine (Val142Ile) amino acid substitution consistent with hereditary ATTR-CA. To definitively assess for endomyocardial ATTR involvement the patient was sent for cardiac scintigraphy using 99mTc-labeled pyrophosphate which returned negative with a cardiac to contralateral lung uptake ratio of 1.001 and visual grade of 0. With suspicion still high, an endomyocardial biopsy was pursued and stained positive for congo red with mass spectrometry confirming hereditary Val142Ile ATTR-CA, allowing for tafamidis initiation.Conclusion:We present a complex diagnostic case of ATTR amyloid in a patient who is at high risk for plasma cell dyscrasias with an abnormal kappa/lambda ratio, non-diagnostic CMR, and negative nuclear scan. Despite significant advances in imaging techniques allowing for less invasive diagnostics, this case highlights the role of endomyocardial biopsy in complicated cases.

Circulation, Volume 146, Issue Suppl_1, Page A13131-A13131, November 8, 2022. Introduction:Few studies have described the characteristics of the left atrial appendage (LAA) using three dimensional (3D) transesophageal echocardiography (TEE) in atrial fibrillation (AF).Hypothesis:We hypothesized that 3D characteristics of the LAA could further characterize patients in AF.Methods:We prospectively evaluated 156 patients hospitalized for AF with two-dimensional (2D) transthoracic and 3D TEE of the LAA within 24 hours of admission. 3D parameters were off-line analysed with Tomtec software (4D Cardio-View, Generic Volume, Philips) (Figure 1A). Patients were divided into two groups according to the cardiac rhythm at 2 years of follow up: restoration of sinus rhythm (SR group, 107 patients) or persistence of atrial fibrillation (AF group, 49 patients).Results:The mean age of the population was 66±11 years and 95 (61%) patients were male. At admission using 2D transthoracic echocardiography, AF group had in comparison with SR group higher left atrial end-systolic volume indexed (respectively 48.0 (38.7-57.0) versus 41.8 (35.0-51.5) ml/m2, p=0.0096), higher E velocity (respectively 0.90 (0.78-1.00) versus 0.76 (0.62-0.91) m/s, p= 0.0001) and higher pulmonary arterial pressure (respectively 31 (25-38) versus 28 (23-33) mmHg, p=0.0142). There were no significant differences in left ventricle ejection fraction and right atrial end-systolic volume indexed. At admission using 2D TEE, AF group had in comparison with SR group lower emptying flow velocity (29 (20-38) versus 38 (26-53) cm/s, p=0.002) and filling flow velocity (29 (20-39) versus 40 (29-56) cm/s, p=0.001) of the LAA. In 3D TEE, AF group had higher 3D end-systolic and end-diastolic LAA volumes (non-indexed and indexed) and no significant differences in LAA ostium in comparison with SR group (Figure 1B).Conclusions:3D evaluation of the LAA reflects a degree of cardiac cavities remodeling in AF and seems to be associated with the evolution of cardiac rhythm at two-years follow-up.

Circulation, Volume 146, Issue Suppl_1, Page A11732-A11732, November 8, 2022. Introduction:Recent data shows that when adults are discharged after hospitalization for acute heart failure (HF), a clinic follow up with either cardiology or general medicine within 7 days results in significantly lower chances of 30 day readmissions. We sought to analyze the trends of clinic follow up after acute HF hospitalization and the associated barriers and facilitators at our safety net hospital.Methods:Data was extracted from the electronic medical records using ICD 9,10 codes for acute HF admissions between Jan 2019 and Dec 2021. Quarterly trends of rates of clinic follow up were analyzed over the past 3 years; t-test was used to assess for statistical significance. Multivariable logistic regression models were constructed to test the association between patient level factors and clinic follow up after adjusting for sociodemographic factors. A p value < 0.05 was used to establish significance.Results:Of 1,037 patients admitted for acute HF between 2019-2021, 29.5% were 65 years or older, 64.7% were males, 48.7% were Black and 16.6% were uninsured. Only 8% and 23.1% had a 7 and 14 day clinic follow up respectively. Of those with scheduled follow up 65% and 56% showed up to their appointments at 7 and 14 days respectively. Overtime we noted an increase in the proportion of encounters with a 7 day follow up although the effective follow up (after accounting for no-shows) remained unchanged. Patients that had an inpatient cardiology consult had higher odds of getting a 7 day follow up (OR=1.42, p value = 0.001) after adjusting for age, gender, insurance status and race (black > white, OR = 1.34, p

Circulation, Volume 146, Issue Suppl_1, Page A10067-A10067, November 8, 2022. Introduction:Preeclampsia is associated with cardiovascular disease (CVD), and follow-up in women for CVD prevention is essential. We examined racial differences in follow-up with primary or cardiology care and assessed if social factors modified that association.Methods:We conducted our analysis in an administrative database (Optum’s de-identified Clinformatics® Data Mart) and identified women with preeclampsia diagnosed from 9/2014-9/2019. Odds of a follow-up visit with a primary care provider or cardiologist within 6 months after delivery were compared among Black versus White women using multivariable logistic regression models adjusting for age, comorbidities (by Elixhauser score), income, education, insurance type, and number of adults per household. We examined the effect modification of education and income on follow-up by race. A Cox proportional hazard model was used to compare time to follow-up.Results:Of 22,887 women with a diagnosis of preeclampsia (age 31.7±5.6 years), 2,736 (12.0%) were identified as Black race and 3440 (15.0%) Hispanic. Education, income, and comorbidities differed by race and ethnicity. Black women had lower odds of follow-up with a primary care provider or cardiologist within 6 months after delivery: adjusted odds ratio (aOR) 0.85 [95% confidence interval (CI) 0.78-0.92] compared with White women and were 13% less likely to have follow-up in adjusted time to event models. Hispanic women also had lower odds of follow-up: aOR 0.84 [95% CI 0.78-0.91] and were 12% less likely to have follow-up compared with white women. There was an effect modification of education by race on follow-up (p for interaction=0.001), but not income (p for interaction=0.14).Conclusions:Black and Hispanic women have decreased odds of follow-up with a primary care provider or cardiologist than White women in the 6 months postpartum, a disparity that may be modified by socioeconomic factors. Improving follow-up care for Black women, particularly those with less than a college-level education, may enhance CVD prevention.

Circulation, Volume 146, Issue Suppl_1, Page A9409-A9409, November 8, 2022. Introduction:Adults with congenital heart disease (CHD) benefit from cardiology follow-up. However, benefit for children is less clear as studies of follow-up patterns in children with CHD are limited.Hypothesis:There are identifiable risks for loss to cardiology follow-up in children with CHD, and loss to follow-up changes healthcare utilization and outcomes.Methods:Our cohort included children

Circulation, Volume 146, Issue Suppl_1, Page A11762-A11762, November 8, 2022. Background:Considering a paucity of pooled data on the influence of Body Mass Index (BMI) on long-term cardiac outcomes in individuals with Hypertrophic Obstructive Cardiomyopathy(HOCM), we conducted this systematic review.Methods:PUBMED, Scopus, EMBASE and Google Scholar were used to screen studies reporting Mortality/Major Adverse Cardiac Events (MACE) and Sudden Cardiac Death(SCD) among obese vs nonobese HOCM patients. Pooled odds ratios(OR) and heterogeneity were assessed with random-effects models and I2statistics. Subgroup analysis was performed to assess the risk by study type, sample size, country and procedure. The leave-one-study-out method was used for sensitivity analysis.Results:Of the 178 titles screened, we included 13 studies published between 2016-2022 with a total of 2,409,397 HOCM patients followed for a median of 6 years (1.8-8.2 year range). The sample had a higher proportion of males (61.33%) with a mean age of 56.3 years (37-78 year range). The unadjusted [OR=1.55(1.09-2.21), I2=96%] and adjusted [OR=1.28 (1.06-1.54), I2=82.7%] pooled odds of all-cause mortality were significantly higher with increased BMI. On subgroup analyses, prospective studies showed higher odds [n=3, 1.79 (1.23-2.6), p=1000:OR=1.39(1.24-1.57)] but lower sample sizes from other countries [n

Circulation, Volume 146, Issue Suppl_1, Page A14713-A14713, November 8, 2022. INTRODUCTION : Only limited data are available and long term follow up studies are insufficient about optimal treatment in patients with chronic total occlusion of a single coronary artery.METHODS : A total of 2,024 patients with CTO were retrospectively enrolled in Samsung Medical Center CTO registry between March 2003 and February 2012 and followed-up for 10 years. Patients underwent coronary artery bypass graft (n = 477) and Patients with multi-vessel CTO (n = 1,112) were excluded. Finally patients with chronic total occlusion of a single coronary artery (n = 435) were analyzed. Divided into two groups, optimal medical group (OMT, n = 147) and percutaneous coronary intervention group (PCI, n = 288) in accordance with initial treatment strategy. Cox regression analysis and propensity score matching was performed to adjust for confounding factors. Primary outcome was cardiac death.RESULT : During the follow up 10 years, we identified that there were no significant differences between OMT group and PCI group in rate of cardiac death (adjusted HR, 0.57 [95% CI, 0.26-1.24]; P=0.16) as well as rate of major adverse cardiac event (adjusted HR, 0.79 [95% CI, 0.52-1.19]; P=0.26) . After propensity score matching analyses, OMT group and PCI group still have no significant differences in rate of cardiac death (adjusted HR, 0.54 [95% CI, 0.24-1.19]; P=0.13) and rate of MACE (adjusted HR, 0.97 [95% CI, 0.62-1.52]; P=0.89).CONCLUSION : This retrospective observational study supported that as an initial treatment strategy in patients of single vessel CTO, PCI did not decrease the rate of cardiac death or MACE.KEYWORD : Chronic total occlusion, Optimal medical treatment, Percutaneous coronary intervention

Circulation, Volume 146, Issue Suppl_1, Page A14138-A14138, November 8, 2022. Background:Both the retro-aortic anomalous coronary (RAC) and bleb signs are underrecognized echocardiographic findings suggestive of an anomalous left circumflex (LCx) coursing posterior to the aortic root. We present a patient in whom these echocardiographic signs were identified and confirmed on additional imaging.Case Presentation:A 77-year-old male presented with heart failure secondary to severe MR. In the apical 4 chamber (A4C) view, tilting anterior demonstrated the RAC sign, a highly echogenic tubular structure in the retro-aortic region above the mitral valve (panel A). In the parasternal long-axis view, the bleb sign, a round structure next to the aorto-mitral curtain, was identified (panel B). The RAC sign was also seen in the short-axis (SAX) as a tunnel-shaped structure behind the aortic root. This structure also represents an orthogonal view of the “bleb sign” (panel C). An anomalous LCx was suspected and was confirmed on both CTA and coronary angiography (panel D). The patient underwent successful mitral valve replacement.Discussion:The most common coronary anomaly is a LCx artery arising from the right sinus of Valsalva. Traditionally, either coronary angiography or CTA, has been required for diagnosis; however, these tests are expensive and invasive. The bleb and RAC signs must be differentiated from other more common echocardiographic findings. In the A4C view, the RAC sign can be mistaken for the coronary sinus, which is typically a more posterior structure, or for calcifications of the aortic valve, which would move with the valve and would not have internal anechoic components. The bleb sign can be differentiated from an abscess of the mitral-aortic fibrosa by identifying the tubular retro-aortic appearance of the structure in the SAX view.Conclusion:The RAC and bleb signs offer a noninvasive means identifying an anomalous LCx; however, they must be differentiated from other cardiac structures which can mimic their appearance.

Circulation, Volume 146, Issue Suppl_1, Page A234-A234, November 8, 2022. Introduction:Despite receiving conventional (C) CPR and other standard treatments, almost all out-of-hospital cardiac arrest (OHCA) patients with non-shockable presentations will still die. As non-shockable presentations comprise nearly 80% of all OHCA cases, alternative treatment strategies are clearly indicated.Hypothesis:Compared to C-CPR controls, treatment with AHUP CPR (defined as the combination of an automated head up positioning [AHUP] device, an impedance threshold device [ITD], and manual and/or automated suction cup-based CPR), increases the probability of survival (SURV) to hospital discharge as well as neurologically favorable survival (N-SURV) for OHCA patients with (first recorded) non-shockable presentations.Methods:Prospectively collected data were obtained from a national AHUP CPR registry from 5 early adopting first responder EMS agencies that routinely initiated immediate AHUP CPR and tracked OHCA outcomes. Comparisons were made to C-CPR controls using individual patient data from high-performing prehospital systems participating in the NIH-funded Resuscitation Outcomes Consortium ROC-PRIMED and ResQTrial studies. AHUP and C-CPR patients presenting with a non-shockable rhythm were matched for the same discrete time interval from the 9-1-1 call to EMS CPR start time and propensity score for the key baseline covariables associated with outcome (e.g., age, sex, bystander-witnessed, bystander CPR) with a 1:1 ratio. Neuro-intact survival was defined as a modified Rankin Scale

Circulation, Volume 146, Issue Suppl_1, Page A9265-A9265, November 8, 2022. Introduction:Remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) has been shown to improve cardiovascular morbidity and mortality. To date, no studies have investigated disparities in utilization and delivery of RM. This study was performed to investigate if racial and socioeconomic disparities are present in CIED RM.Methods:Retrospective observational cohort study at a single tertiary care center in the United States. Patients who received a newly implanted CIED or device upgrade between 01/17 to 12/20 were included. Patients were classified as RM positive when they underwent at least ≥2 remote interrogations per year during follow-up.Results:Of all eligible patients, 2520 patients were included and 35% were female. The mean follow-up was 25 months. Mean age was 71±14 years. Pacemakers constituted 66% of implanted devices, while 26% were ICDs, and 8% CRT-Ds. Most patients (83%) were White non-Hispanic (WNH) patients. During follow-up, 66% of patients were classified as RM positive. In an adjusted regression model, these patients were younger (p=0.025) and more frequently had an ICD (HR=1.68; p

Circulation, Volume 146, Issue Suppl_1, Page A13005-A13005, November 8, 2022. Trans-catheter aortic valve replacement (TAVR) via tortuous iliofemoral access with prior endovascular aneurysm repair (EVAR) is challenging.83 year old male with severe aortic stenosis and prior EVAR was evaluated for TAVR with 29 mm Edwards Sapien 3 valve. Right femoral access was planned with ipsilateral protection. CT angiogram showed EVAR with tortuosity, rigidity, and graft protrusion concerning for advancement of equipment. The right iliofemoral system was accessed using a 4F radial sheath, Judkins JR4 catheter, and 0.035” angled glide wire exchanged for Amplatz Superstiff wire. A 30 cm 6F sheath was advanced over the wire followed by additional Superstiff buddy wire. Two Proglides were deployed over two separate wires, without rewiring. To overcome friction on removing second Proglide, predilatation of the arteriotomy should have been performed with a 8-9F sheath. An 8F sheath was advanced over one of two Superstiff wires. A V18 0.018” wire was placed in the ipsilateral protect site, exchanged for a third Superstiff wire to ease insertion of the Edwards sheath. The sheath was advanced followed by successful valve deployment. After removing the delivery system, two pre-deployed Proglides closed the arteriotomy site.Detailed planning enables operators to overcome challenges using the following strategies: 1) avoid unnecessary rewiring of the iliofemoral system by use of a 30 cm 6F sheath, 2) predilate the TAVR arteriotomy with larger sheaths prior to deploying Proglides to avoid limited manipulation space for Proglides and two wires, 3) use buddy wires if TAVR sheath advancement has failed over one wire and consider additional buddy wires from within the TAVR arteriotomy or ipsilateral protection site, and 4) use ipsilateral protection to avoid challenges of crossing over from contralateral iliofemoral. Although trans-EVAR TAVR remains somewhat unpredictable, these strategies may simplify and reduce the inherent failure rate of such procedures.

Circulation, Volume 146, Issue Suppl_1, Page A11885-A11885, November 8, 2022. Background:cardiac magnetic resonance (CMR) is central for diagnosis, follow up and prognostic stratification of acute myocarditis. Late gadolinium enhancement (LGE) extent and persistence at follow-up represents a negative prognostic marker. However, time course of oedema resolution and LGE stabilization and optimal timing to repeat CMR are unclear.Hypothesis:we assessed time course of oedema and LGE evolution to identify optimal timing to repeat CMR in acute myocarditis.Methods:36 acute myocarditis patients (35M, 28,8±10,3 years) underwent CMR at clinical presentation (CMR-1), after 3 months (CMR-2) and after 12-months (CMR-3). We assessed oedema and LGE and measured left ventricular ejection fraction (LVEF) and indexed mass (iLVM). After CMR-3 all patients were followed up yearly with clinical evaluation, Holter ECG and echocardiography.Results:all patients had oedema and LGE at CMR-1. At CMR-2 significant reduction of oedema (T2 positive segments 0,4±0,9 vs 4,1±3,2 p

Circulation, Volume 146, Issue Suppl_1, Page A12498-A12498, November 8, 2022. Introduction:One of the most well-established risk markers for sudden cardiac death is non-sustained ventricular tachycardia (NSVT; 3 ventricular beats with a rate of ≥120 bpm, lasting for

Circulation, Volume 146, Issue Suppl_1, Page A15674-A15674, November 8, 2022. Introduction:Cardiac amyloidosis (CA) is an underdiagnosed cause of heart failure. Echocardiography provides an excellent screening tool for cardiac amyloidosis. For patients with echocardiographic findings suggestive of cardiac amyloidosis, it is unknown how frequently follow-up imaging such as 99mTc PYP-scan or cardiac MRI is obtained. Diagnosis rates after a suggestive echocardiogram as well as disparities in rates of follow-up imaging and subsequent CA diagnosis are also unknown.Methods:We extracted all index cardiac echocardiograms at our institutions of adult patients that were suggestive of a possible diagnosis of CA, which was defined as: moderate or worse left ventricular concentric hypertrophy plus grade II or grade III diastolic dysfunction or diastology could not be determined due to arrhythmia in those with atrial fibrillation. Patients with known diagnosis of amyloidosis were excluded. We determined which patients underwent further testing with99mTc-PYP scan or cardiac MRI. We performed a population based case control study in which we compared clinical and demographic factors between those who underwent follow-up testing with either PYP scan or cardiac MRI (cases) vs those who did not (controls).Results:Of 1348 echoes that met inclusion criteria, only 110 (8.2%) underwent PYP scan or cardiac MRI. Of those, 10.0 (11%) patients ultimately were diagnosed with CA. Between cases and controls, there was no difference in age, gender, or race/ethnicity. There were no differences in rates of HFrEF or HFpEF between cases and controls. Cases had lower rates of CKD (27% vs. 40%, p=0.01) and ESRD (8.2% vs 15%, p=0.03) and had higher rates of carpal tunnel disease (12% vs. 6%), p

Circulation, Volume 146, Issue Suppl_1, Page A14281-A14281, November 8, 2022. Background:The predictive value of termination of atrial fibrillation (AF) with direct-current (DC) cardioversion (CV) during catheter ablation (CA) during a long-term follow-up is not known.Methods:We studied the long-term success of CV during ablation in patients who underwent catheter ablation of AF and followed them for recurrence of AF/atrial flutter (AFL).Results:Of 187 patients (male: 75%, mean age: 60.3 ± 10.7 years), 96 (51.3%) patients required DC cardioversion during the initial CA. A mean number of 1.4 ± 0.6 ablations (p=NS) were performed during follow-up in both groups. There were no significant differences in baseline characteristics including age, gender, race, body mass index, left ventricular ejection fraction, and presence of hypertension, diabetes, and valvular disease. During a median (±1SE) follow-up of 5.23 ± 0.17 years, a significantly higher percentage of patients who needed CV during CA had recurrence of AF/AFL as compared to patients who did not need CV to terminate AF during CA (39.6 vs 16.5%, p < 0.001). Cox regression analysis confirmed DC cardioversion during ablation as a predictor of recurrence of AF/AFL at time of last follow-up (OR: 2.78, 95% CI 1.52 to 5.10, p < 0.001). Kaplan-Meier survival analysis shows significantly decreased time to recurrence in patients who had CV during initial ablation than those who did not require DC cardioversion (log-rank p

Circulation, Volume 146, Issue Suppl_1, Page A10849-A10849, November 8, 2022. Introduction:Long COVID syndrome is defined as physical, cognitive and psychological symptoms that persist for over 12 weeks following the acute illness and are not explained by other diagnosis.Aim:To assess medical and health-related quality of life (HR QOL) outcomes at medium-term follow-up in subjects previously infected with COVID-19.Methods:2646 patients who were diagnosed with COVID-19 infection were randomly selected. They were interviewed to assess for symptoms and HR QOL using a post-COVID questionnaire and Short Form Survey (SF-36) respectively. Blood investigations were taken.Results:The median age was 44 years (IQR 31-55), 49% were males. 5% were hospitalised and 1% intubated. Smokers comprised 17%, 10% were ex-smokers. 17% suffered from hypertension, 11% hyperlipidaemia, ischaemic heart disease was present in 2%, heart failure in 1%, obesity in 18%, chronic kidney disease in 0.2%, chronic respiratory disease in 7% and type 2 diabetes mellitus (DM) in 7%.Median time to follow up was 142 days (IQR 128-161). 22% of participants claimed they felt worse than before. Most common symptoms were anosmia (55%), abnormal taste (53%), fatigue (23%), dyspnoea (23%), headache (20%) and myalgia (15%). The SF-36 survey showed that hospitalized patients fared worse in all domains except for role-emotional.New onset DM was diagnosed in 50 patients, similar to the rate of undiagnosed DM in the population. Hospitalised patients had significantly higher liver transaminases, FPG, HbA1c, uric acid, RDW, MPV, triglyceride levels and troponin levels but lower eGFR and HDL-cholesterol at follow-up. The differences in RDW, MPV, triglyceride, GGT and FPG remained significant after adjusting for confounders (Table 1).Conclusions:A significant proportion of post-COVID patients were symptomatic at medium-term follow-up. Hospitalised patients had more biochemical and haematological abnormalities, suggesting ongoing inflammation in those more severely affected.